CMS discharge rule requires patient, post-acute care data access

A new rule empowers patients to be active participants in discharge planning and seeks to ensure seamless exchange of their data between acute care and post-acute care settings.

The rule, from the Centers for Medicare and Medicaid Services, revises the discharge planning requirements that long-term care hospitals and inpatient rehabilitation facilities, inpatient psychiatric facilities, children’s hospitals, cancer hospitals, critical access hospitals and home health agencies must meet to participate in the Medicare and Medicaid programs.


“This final rule also implements discharge planning requirements which will give patients and their families access to information that will help them to make informed decisions about their post-acute care while addressing their goals of care and treatment preferences, which may ultimately reduce their chances of being re-hospitalized,” according to the agency.

Specifically, the CMS final rule requires the following:

• New discharge planning requirements, as mandated by the IMPACT act for hospitals, home health agencies and critical access hospitals, requiring facilities to assist patients, their families, or the patient’s representative in selecting a post-acute care services provider or supplier by using and sharing post-acute data on quality measures and resource use measures.

• New discharge planning process requirements for critical access hospitals and home health agencies that require a hospital to discharge the patient, and also transfer or refer the patient where applicable, along with his or her necessary medical information (current course of illness and treatment, post-discharge goals of care and treatment preferences), at the time of discharge, to not only the appropriate post-acute care service providers and suppliers, facilities, agencies, but also to other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care.

• Revised compliance language for home health agencies that now requires them to send all necessary medical information (current course of illness and treatment, post-discharge goals of care and treatment preferences) to the receiving facility or healthcare practitioner to ensure the safe and effective transition of care, and that the home health agency must comply with requests made by the receiving facility or healthcare practitioner for additional clinical information necessary for treatment of the patient.

• New requirement that sends necessary medical information to the receiving facility or appropriate post-acute care provider (including the practitioner responsible for the patient’s follow-up care) after a patient is discharged from the hospital or transferred to another post-acute care provider or, for home health agencies, another agency.

• Hospitals must ensure and support patients’ rights to access their medical records in the form and format requested by the patient, if it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically).

“By demystifying the discharge planning process, we are improving care coordination and making the system work better for patients.” said CMS Administrator Seema Verma in a written statement. “Patients will now no longer be an afterthought; they’ll be in the driver’s seat, playing an active role in their care transitions to ensure seamless coordination of care."